Healthcare Provider Details

I. General information

NPI: 1104777598
Provider Name (Legal Business Name): JEREMY RON ALQUIZAR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/03/2026
Last Update Date: 02/03/2026
Certification Date: 02/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1851 OLD MOULTRIE RD
ST AUGUSTINE FL
32084-4168
US

IV. Provider business mailing address

7154 AMBROSIUS WAY
JACKSONVILLE FL
32258-6541
US

V. Phone/Fax

Practice location:
  • Phone: 904-824-8088
  • Fax:
Mailing address:
  • Phone: 904-887-7459
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberAPRN11043624
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: